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Fri Sep 1 12:19:19 BST 2006

Hi Mark;

Thanks for the comments, and I agree with the bit about semi-conscious patient and the finger (Most of the time LMA's do sit ok on blind insertion anyway as you will no doubt know, but added that to reitarate the method!)

Really interested to hear that you did a thyroid using the LMA/ETT method.  Is this something you normally do or did due to the suggestion? As you may have guessed I am UK trained anaesthetic ODP, currently working in NZ with my main specialities intrest being in ENT/Max-Fax, Paeds & Neonates, and it really is intresting to see different techniques/practises for the same procedures.

The main place i worked at in the UK, (East Anglia) we just used size 7 ETT North Oral/nasal or if case dictated we used MLT's, and nerve stimulators, we very rarely checked the chords visually (other than routine suctioning afterwards).  Main Anaesthesia was TCI Propofol and Remi running at 2.5mcg/kg; Isoflurane on standby if required; with morphine about 5 mins before wake up or PRN, and use of BIS...which of course  is another topic : ) 

Chris

________________________________

From: MARK FORREST [mailto:atacc.doc at btinternet.com]
Sent: Fri 01/09/2006 12:47
To: Trauma &amp; Critical Care mailing list
Subject: Re: WHAT DO YOU SUGGEST ?

Hi Chris,
Agree with much of what you say, but I don't use the current recommended insertion method as I am NOT PUTTING MY FINGER IN THE MOUTH OF A SEMI-CONSCIOUS TRAUMA PATIENT!

Incidentally, used the 'Size 5.0 MLT tube through the LMA' method today in an elective thyroid...great way to check the cords during the case and post-op. Inserted it blind and it entered the larynx first pass, as usual. During the case for a cord check, I pull the tube back into the LMA, maintain anaesthesia with this airway, whilst visualising the cords during nerve stimulation through the fibreoptic scope, then advance the tube back through the larynx for the rest of surgery. Post-op, remove the tube and maintain airway to recovery with the LMA...works a treat and ENT colleague loves it!
Cheers
Mark F
UK

----- Original Message ----
From: Christopher Clarke (CMDHB) <Chris.Clarke at middlemore.co.nz>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, 1 September, 2006 1:31:57 AM
Subject: RE: WHAT DO YOU SUGGEST ?

Hi Guys;

Just thought I would add a bit more male chemical to this conversation!
But before I do can we look at the basic facts please??

Fact 1) LMA's firstly were designed by a British anaestheist to assist
the anaesthetist during operative procedures when intubation was not
required.

Fact 2) Loads and Loads of literature that can be added and thrown out
depending on its source and the finance backing the article; but on the
whole it is widely accepted that LMA's althougth not 110% fantastic at
securing an airway do secure an airway 99.9999% of the time. 

Fact 3) People who vomit, do so either actively or passively, if they
are actively vomiting..remove the LMA --- They still have reflexes!

Fact 4) If the are passively vomiting, this would surely indicate a very
low GCS score or equivelant, and therefore intubation is recommended if
not already done!

If you cannot intubate due to whatever reason, chance's are that person
will die anyway and by securing an airway of any description even if
they have aspirated is better than none....hospital docs can deal with
chest infections, and for the ones that aspirate and do indeed die
chances are they would have done so anyway, so anything anydbody can do
to help is better than walking away and leaving them.

Now I can hear the cries of the positive people out there already
stating many people have survived after a GCS of 1 or 2..blah blah blah;
so for those amongst you who cannot intubate at the side of the road
under a car etc but can secure an airway using an LMA..why not do
this...

Fact 5) Place a Classic (Normal) LMA correctly and ensure it is seated
correctly...(and this where many people espcially EMS/SHO's/Reg's go
wrong because LMA's are so easy to use.....)

Take a cuffed size 5 ETT, this will fit down through a normal LMA tube
and if the LMA is seated correctly will go through the Chords..Blow up
the cuff with no more than 10mls air and hey presto you have a 110%
secure airway. 

Yep it doesn't like good..but hey under a wagon nothing looks good does
it??? (Unless of course you have a fetish with oil)

THE EMPHASIS ON THIS IS THAT THE LMA IS PLACED CORRECTLY, USING THE
FINGER INTO THE MOUTH TECHNQIUE AND FOLLOWING THE HARD PALETTE BACK
UNTIL THE LMA POPS INTO PLACE.

Regards to everyone;

By the way, I presumed..maybe me but I don't know ....that this forum
was about advancing ways to treat patients from side of road to
hospital, not to bitch and moan about who does the most work, cos if
that's what this is about anaesthetic assistants/Techs/ODP's do!!!!

Take care

Chris

-----Original Message-----
From: Mike [mailto:mmackinnon at cox.net]
Sent: Friday, 1 September 2006 11:23
To: Trauma &amp; Critical Care mailing list
Subject: Re: WHAT DO YOU SUGGEST ?

Lets try that again.

Oh my

I see your quick to make a statement without backing it up and i guess
thats OK?

first, please do not compare the OR with the pre hospital arena, its
like apples an oranges. When was the last time you drug someone out of a
car, popped em on a backboard, tied em to it and then drove them
anywhere? They are lying nice and prone on the OR table. NOT the same
thing

Im not being dramatic, the Literature backs me up. Now, if you would
like, i could post the other 50 orso articles which prove my point even
in the OR.
It is a common saying amoung anesthetists the LMA Let eM Aspirate. The
reason why is to REMIND you that it does not stop aspiration. really,
look at he design, that should be self evident. It rarely seats
perfectly and the sizes are never perfect. Aspiration is a real issue
with LMAs.

Here is my "nonesense". Next time, consider doing a medline search
before you challenge someone.

>From the  British Journal of Anaesthesia 2004 93(4):579-582

Aspiration and the laryngeal mask airway: three cases and a review of
the
literature
C. Keller1, J. Brimacombe2,*, J. Bittersohl3, P. Lirk1 and A. von
Goedecke1
1 Department of Anaesthesia and Intensive Care Medicine,
Leopold-Franzens
University, Innsbruck, Austria. 2 James Cook University, Department of
Anaesthesia and Intensive Care, Cairns Base Hospital, Australia. 3
Department of Anaesthesiology and Intensive Care Medicine,
Philipps-University, Marburg, Germany

* Corresponding author. E-mail: jbrimaco at bigpond.net.au

The primary limitation of the laryngeal mask airway (LMA(r)) is that it
does
not reliably protect the lungs from regurgitated stomach content. We
describe three cases of aspiration associated with the LMA, including
the
first brain injury, the first death, and the first associated with the
intubating LMA, and review the 20 specific case reports of aspiration
associated with the LMA that we were able to find described in the
literature.

O. Hung and J. A. Law
Advances in airway management
Can J Anesth, June 1, 2006; 53(6): 628 - 631.

R. S. Vaughan, I. T. Campbell, S. Patel, G. Turner, J. Brimacombe, and
C.
Keller
Aspiration and the laryngeal mask airway
Br. J. Anaesth., April 1, 2005; 94(4): 545 - 547.

Cook C, Gande AR. Aspiration and death associated with the use of the
laryngeal mask airway.
Br J Anaesth. 2005 Sep;95(3):425-6

Brimacombe JR, Berry A. The incidence of aspiration associated with the

laryngeal mask airway: a meta-analysis of published literature.
J Clin Anesth. 1995 Jun;7(4):297-305.

Ismail-Zade IA, Vanner RG. Regurgitation and aspiration of gastric
contents
in a child during general anaesthesia using the laryngeal mask airway.
Paediatr Anaesth. 1996;6(4):325-8

Campbell IT.  Aspiration and the laryngeal mask airway.
Br J Anaesth. 2005 Apr;94(4):545-6

Cassinello F, Rodrigo FJ, Munoz-Alameda L, Perez-Tejerizo G, Vallejo D.
Postoperative pulmonary aspiration of gastric contents in an infant
after
general anesthesia with laryngeal mask airway (LMA)
Anesth Analg. 2000 Jun;90(6):1457.

Griffin RM, Hatcher IS.  Aspiration pneumonia and the laryngeal mask
airway.
Anaesthesia. 1990 Dec;45(12):1039-40.
----- Original Message -----
From: "Michael Shuster" <subs2subs at poky.ca>
To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
Sent: Thursday, August 31, 2006 3:58 PM
Subject: RE: WHAT DO YOU SUGGEST ?

> What nonsense.
>
> There's absolutely no evidence that there's any difference in rate of
> aspiration between LMA, Combitube or endotracheal tube.  Studies have
been
> done with each of these devices in the OR using methylene blue.  All
> performed well (but not perfectly).  Studies of each of these devices
in
> resuscitation have not shown any differences in rates of aspiration.
>
> Michael
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Mike
> Sent: Thursday, August 31, 2006 4:44 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: WHAT DO YOU SUGGEST ?
>
> you know what LMA stands for?
>
> Let eM Aspirate.
>
> LMAs have no place in EMS.  ILMAs are the best choice or even a
combitube
> will protect against aspiration better than an LMA.
>
> m
> ----- Original Message -----
> From: "MARK FORREST" <atacc.doc at btinternet.com>
> To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Thursday, August 31, 2006 3:06 PM
> Subject: Re: WHAT DO YOU SUGGEST ?
>
>
>> LMA......simple, quick, reliable and easy to convert to
>> intubation/definitive airway as soon as possible...why struggle!
>> Mark F
>> Anaes/Crit Care Cons,UK
>>
>>
>> ----- Original Message ----
>> From: ofiara at comcast.net
>> To: trauma-list at trauma.org
>> Sent: Thursday, 31 August, 2006 10:03:42 PM
>> Subject: WHAT DO YOU SUGGEST ?
>>
>>
>>>From an EMS standpoint, with the various pt.population,(old to
young).
>>>Reasons for an advanced airway:(trauma-medical-burns), and the places
you
>>>may be intubating,( the box, a darkly lighted small room in a
house-on
>>>scene of a MVC), what do you suggust as a back-up to the ETT. A
>>>Combi-tube, a LMA or a bougie ? Thanks  for any input.
>>  Larry Ofiara, R.N.
>> --
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